MEDICAL INSURANCE GLOSSARY

  Coinsurance
  Co-payment or Co-pay
  Deductible
  Emergency Services
  Exclusions
  Medical Emergency
  Medical Necessary
  Out-of-pocket expenses
  Pre-existing condition
  Premium
  Provider
Coinsurance

The amount you are required to pay after you have met your deductible. The coinsurance rate is usually an expressed percentage. Example: If the insurance company pays 80% of the claim. You pay 20%.

Co-payment or Co-pay

Refers to the payment that must be made at the time of service for Physician Office Visits

Deductible

Is a specified dollar amount which must be paid by the covered individual in each deductible accumulation period before payment of benefits will be made by the insurance company.

Emergency Services

Services provided within 48 hour of an injury or medical emergency.

Exclusions

Specific conditions or circumstances for which the policy will not provide benefits.

Medical Emergency

The sudden onset of a medical condition with acute symptoms of severity that the absence of immediate medical condition could result in:

A) permanently placing the patients health in jeopardy;
B) causing other serious medical consequences;
C) causing serious impairment to bodily functions;
D) causing serious and permanent dysfunctions to any body part;

Medical Necessary

Describes health care treatments, services or supplies which are appropriate and consistent with the diagnosis and treatment of a medical condition according to generally accepted medical standards.

Out-of-pocket expenses

Refers to the amount a covered person will have to pay Out of their pocket in a calendar year.

Pre-existing condition

Condition for which a person received medical care, treatment, services, medication, diagnosis, or consultation 12 months prior to the insured persons effective date of coverage or a condition that produced symptoms that are distinct and significant enough to establish the onset of a condition or that the condition manifested itself, where a person learned in medicine would be able to diagnose the condition because of those symptoms.

Premium

The amount you pay in exchange for insurance coverage.

Provider

Any person (Doctor, Nurse, Dentist) or institution (hospital or clinic) that provides medical care.

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